Monife
Forum Newbie
Topics: 4
Posts: 7
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Hi all,
Could someone please tell me the proper order to write the patient note.I woul be happy if you coul give me a sample of the right way to do it.I want to practise that.
Thanks
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| Natali
Forum Newbie
Topics: 0
Posts: 8
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Hi, Monife.
Fa is good for PN. If you want there are some examples. But on the exam it is important to focus on the positive and negative signs of the pertinent history.
General survey: Alert, helthy/ill appearing woman/man, WG/WD, resting comfortably on the examining table/or pacing up and down...
Vital signs:...
Skin: no rash, or describe the rash
HEENT: NC/AT
PERRLA
Disc margins are sharp, fundi w/o hemorrhages or exudates
External ear canal patent, tympanic membranes with good cone of light
Oral mucosa pink, w/o enlarged tonsills, dentition good, pharynx w/o exudates.
Neck: supple, w/o thyromegaly, no lymphadenopathy.
Thorax & lungs: thorax symmetric with good expansion. Lungs resonant, breath sounds vesicular/ or CAT. TF N. No digital clubbing.
CVS: JVP 1cm above the sternal angle; carotid upstrokes brisk, w/o bruits.
PMI tapping & nondisplaced
Good S1, S2; no S3, S4, no murmurs
GI: BS active. No tenderness or masses. Liver span 7cm in R MCL; edge smooth, palpble 1cm below RCM Spleen & kidneys not felt. No CVA tenderness.
Peripheral vascular/extremeties: Calves supple, warm w/p edema, nontender. Peripheral pulses are 2+ BL. No stasis, pigmentation or ulcers.
Muskuloskeletal: ROM full in all joints, no swelling or deformities.
Neurologic: MMSE: patient is oriented to person, place and time. Alert and cooperative. Thought coherent
CN 2 trough 12 intact.
Motor: Good bulk & tone; srength 5/5 throughout.
Cerebellar: RAMs, finger to nose & heel to shin intact; gait with normal base
Sensory: pinprick, light touch, position sense, Vibration & stereognosis intact and symmetric throughout. Romberg negative.
Reflexes: 2+ brisk/N & symmetric throughout with Babinski negative.
Use abbreviations if you used to, it saves your time. This sample may appear too long but it is a template not only fot the exam. You can use it in real life .
GL.
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| Monife
Forum Newbie
Topics: 4
Posts: 7
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Thanks so much and all the best as you study too
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